Revisions to End-Stage Renal Disease Payment Policies

Under the Physician Fee Schedule for Calendar Year 2004

On behalf of the more than 46,000 clinically practicing physician assistants who are represented by the American Academy of Physician Assistants, we would like to take this opportunity to submit comments on the proposed changes to the reimbursement methodology for end-stage-renal disease ( Federal Register, Vol. 68, No. 158, August 15, 2003).

 

The American Academy of Physician Assistants (AAPA) is the only national professional organization representing physician assistants (PAs) in all medical specialties. It is estimated that in 2002, 183 million patient visits were made to PAs. Many of those visits were from Medicare beneficiaries.

 

The AAPA has serious concerns about the proposal to fundamentally change the existing capitated payment methodology for end-stage-renal disease (ESRD). While the goal of assuring ESRD patients the highest quality care is one that we all share, we fear that the current proposal may, in fact, compromise both the quality and the continuity of care for dialysis patients.  

 

The PA profession remains strongly committed to the involvement of physicians in the care of ESRD patients. However, it appears that the proposal fails to appropriately recognize the team approach to the delivery of health care and the integral role played by PAs as part of that physician-led team. The proposal suggests a payment formula for face-to-face physician visits. PAs, working with physicians, are specifically authorized by the Medicare program to deliver services that would otherwise be provided by a physician.   Additionally, numerous objective reports and studies continue to demonstrate that the quality of care received by patients is not diminished when PAs deliver care to patients as part of the physician-PA team.

 

It is unclear as to whether the ESRD proposal would allow PAs to provide any of the physician face-to-face visits. We strongly urge that language be included that recognizes the treatment contribution made by PAs to dialysis patients. Limiting the involvement of PAs and certain other appropriately trained non-MD/DO health care professionals could have a substantial negative impact on access to care for ESRD patients, especially those in rural and underserved communities.

 

On another note, it is surprising that the creation of the proposed ESRD G codes bypassed the traditionally accepted pathway through the Current Procedural Terminology (CPT) Committee and Relative Value System Update Committee (RUC). The CPT process has demonstrated itself to be extremely valuable in assuring that code descriptors are clear and appropriate based on current medical practice. According to the Centers for Medicare and Medicaid Services (CMS) and practicing health care professionals, the RUC process is accepted as providing a fair and objective assessment of proper valuation for Medicare medical and surgical services. Failure to utilize the experience and expertise of these two committees lessens the credibility of the process. Our apprehension is that arbitrarily established payment levels will create rank order anomalies among codes.

 

We believe that it is premature to finalize this proposal as part of the 2004 Medicare Physician Fee Schedule. There are too many unanswered questions about both the process and the net impact of the proposal on Medicare ESRD patients. We, therefore, urge CMS to withhold implementation of this proposal.

 

We appreciate the opportunity to comment on the proposed ESRD changes and hope that our comments are useful. If we can be helpful in supplying additional information or details on our comments, please do not hesitate to contact us.

 

Sincerely,

 

Stephen C. Crane, PhD, MPH

Executive Vice President & CEO

 

Last Revised: 10/10/03